I am proud of our society. We provide care to everyone.

She is always a difficult admission. The long chart review. The vague complaints. The entitled attitude. The misdirection. These are expected. As is the cake at her bedside after a diabetic crisis. The two-liter soda after an emergent fluid dialysis. The urine toxicology was positive for cocaine. The staff knows her well. I know her well. I give her the attention, kindness and empathy that I give to every patient. In abundance. But admitting her overnight on an ICU shift was especially unpleasant.

After she settled in, I went to interview her. She grimaced. She told me about her abdominal pain and her headache. She told me about the dizziness and the shortness of breath. And, of course, the chest pain. I listened with my usual attentiveness. Where did I get all the extra fluid in my lungs? I don’t drink any liquids. I know I’m not supposed to. I never miss dialysis. I take my medications. Where did all the water come from? She looked surprised.

After some time though, I saw something different in that hospital bed. Instead of a scared, vulnerable patient I saw a hospital bill. The sum and future cost of her medical care. The countless nights of medical and ICU beds. The CT scans and catheterizations. Dialysis. The endless list society knows nothing about, yet foots the bill. At that moment, I saw it all. The draining of resources. The exploitation of welfare. All on Medicaid. All on the taxpayer. The mythical free lunch. I am not and would never vote for a Republican, but for a moment I thought like one: a moocher and a taker. It was a difficult admission.

It’s natural to take care of those stricken by an unfortunate illness, those who are gracious, or those who comply with doctor’s orders. They are easy. The attention. The kindness. The empathy. They flow from a doctor like saliva from Pavlov’s dog. We are conditioned since medical school to have boundless patience and limitless compassion. We are an engine, and the motor is always running.

And then there are those like my overnight ICU admission. My patient. Our patient. She eats crap, sending her diabetes out of control. She drinks gallons of soda, making dialysis a moving target. She skips medications, driving her heart failure over the edge. She uses cocaine. Yet somehow, on every admission, she receives all the gifts of medicine: a precious hospital bed, a team of nurses, state of the art care, the attention, the kindness, the empathy. I wonder how we do it. How do we find the energy?

I am proud of us. Our society. We provide care to everyone, regardless of station. We do it with the same voracity at all times. No one wants to be on welfare or Medicaid. They do their best with what they have. They don’t want to burden society. But some may be regarded as exceptions. They seem to believe that society owes them. They have no obvious graciousness and no remorse for consuming limited resources. This is how I perceived my ICU patient that night.

And yet, she is our strength. Caring for her defines us. Because it is hard. At the very limits of our attention and kindness and empathy. When we finally stop to ask: Why do we still care for this person? Why do we still give her all that we are? We continue to provide. All the care. All the energy. This is a sign of a society that cares for its people. All of them. I am proud of us.

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I am proud of our society. We provide care to everyone. 27 comments

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QQQ

” They seem to believe that society owes them. They have no obvious graciousness and no remorse for consuming limited resources.”
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I think the founding fathers understood human nature the best they could. Human nature wants everything free, but that’s not reality. So the country was founded as a republic and not a socialist state. They warned about the tyranny that could manifest by giving the government to much power. The original design was individual accountability, letting people keep their own money, then slowly things changed, income tax, social security, medicare, welfare, and (Obamacare) all abused and corrupted by big government.

The founders understood the best person to take care of you IS YOU

Necessity is always the mother of invention.

Michael

I certainly understand why you would believe that.

Contrary to my posts here I am actually somewhat liberal. I believe in the importance of social safety nets and taking care of those among us that have fallen on hard times or are simply unable to cope with life for some reason. I have had times where I have been uninsured or have had challenges and understand other do too. I truly want to help those in need–even if it means a pay cut.

The problem I have is that what is happening here is a wealth transfer from physicians/nurses/PAs (those who do) to rent seekers in suits. The Obama administrations implementation of “Romneycare” (Lets not forget this disaster came from both sides of the aisle) was a windfall for insurance companies and drug companies and of course corporate medicine. I don’t think anyone wants to avoid charity work or work with the poor–we simply do not want to make others wealthy at ours and our families expense (and in reality the expense of the tax payers as well).

For what it is worth this has been happening in many fields for a very long time now–we sat on the sidelines thinking we would not be affected. Woops.

In which case you are making the wrong arguments. The damage to society and to you personally inflicted by one soda drinking, cake eating, cocaine snorting, ingrate poor person, is insignificant compared to the damage done by one champagne sipping, caviar nibbling, Fitbit sporting, groomed to perfection executive. A million offensively helpless poor people put together don’t come anywhere close to the damage inflicted by any one “healthcare” corporation, or “thought leader”.
Considering that each year, since the early 80s, more and more Americans are sliding into poverty, it is just bad strategy to continuously bash regular people, hoping that somehow they will rise to stand up for you, now that the corporate machine is grinding you for dinner. You guys should have all been liberal, and should have all fought for the middle class and good wages for all your patients. As I said a million times before, doctors to the poor cannot by definition make lots of money.
If you want to have a nice income, you must work towards ensuring that your “customers” have enough money to pay you the amounts you are accustomed to. That makes you a liberal, or a socialist or an outright commie, in today’s Davos invented, corporate sponsored, twisted terminology for everything.

Michael

I am not sure what argument that you feel I am making. I never meant to imply that the biggest problems in healthcare are the result of the poor. Furthermore, being fairly young,having come from a lower middle class family, and having worked for years before medical school–I am acutely aware of what has been happening to the American worker since the eighties. I have lived it as both a child seeing my parents stress about increasing bills and decreasing pay, and as a low level employee making far less than I would have for the same job a decade ago. The way American workers have been treated since the 80s is abominable.

I don’t question your intentions, but I do question your means for making the point you are trying to make:
“They seem to believe that society owes them. They have no obvious graciousness and no remorse for consuming limited resources. This is how I perceived my ICU patient that night.”
As you can see here, this imagery is what people zero in on, and then you have to explain that you are “somewhat liberal” and so forth. I think it’s high time to stop highlighting and picking on “exceptions”, even if you are attempting to make a good point in good faith. Caring for people you dislike is indeed noble, but in mind it should be assumed.

No problem, one of the pitfalls of having a common name and having not put much thought into my user name. Hilarious though.

DeceasedMD

Yes rent seeking is the word. Seems rent seeking is ubiquitous in the medical industrial complex. It makes ones head spin to see the crazy cost of a generic. Old technology like ECHO’s that are going up instead of going down in price. Medicine is a profit making machine and less of it is about treating pts

Michael

“medical industrial complex”

That seems like the ideal phrase as it really highlights that medicine is going down the same road as the department of defense– a ton of highly paid private contractors who do not add value to the system siphoning off money that should be going to the boots on the ground and the scientists at DARPA. Look at the disaster that is the joint strike fighter. That is what we have to look forward to if we keep allowing this to happen.

This model is unsustainable in medicine. While the public is willing to spend vast sums on the military it balks at spending it on healthcare. We feel that spending as much on our military as the next ten highest combined is acceptable, but feel that spending a couple thousand more per capita than Norway is insane. Note that physicians are not getting the difference–in the United States physician salary is the lowest as a percentage of healthcare costs than any western country other than Sweden. (OCED 2011)

The point that I took forever to get to is that unlike the military we are going to get some nasty cuts, and I doubt it is going to be the middle/upper managers that are going to feel them.

DeceasedMD

I learned a lot from your post as I knew little about the military indus. complex other than the term. The “medical Industrial complex” was actually coined by a physician around 1980 in JAMA whose name at the moment escapes me but he just passed away fairly recently. Sad there were warnings all the way back to even then that were never taken seriously.
You are right about that term being everywhere . I just saw it used as “Prison Industrial Complex”.
I so agree that in general people devalue or at least feel free medical care is coming to them without paying for it and would rather spend it on the military. On the other hand, the fact there is so much bureaucracy and waste that is destroying the actual practice of medicine is frightening.
You seem very knowledgeable. Was wondering what journals you look at such as the OECD you quoted. Any ideas what countries might have a better medical system than ours? I have come to the conclusion there is really no turning back. As they say on here, CorpMed has the power and I think the writings on the wall.

Michael

Thank you for your kind words.

I believe the term “Military Industrial Complex” was used by president Eisenhower to describe the positive feedback loop created between the government, military, and defense contractors perpetuated by jobs in districts and campaign contributions. I imagine lucrative corporate jobs for connected military officers and super PACs have only made things much worse in recent years. I have a few friends who work in defense so I hear about some staggering waste.

I have always liked OECD publications–going through them directly helps one see through the BS on the news and internet when they attempt to compare medical systems. One of my favorite charts on physician comp shows it as a ratio to the average workers earnings. When you look at that you see that American Doctors are NOT the best paid in the world relative to their countrymen. Americans in general just make more money. This is even before factoring in the insane non dis-chargeable school debt at 6.8 percent that other countries graduates do not face.

As to what country has a better system–I am not sure. I simply do not have enough experience to make an educated assessment. From what I have read we spend substantially more on pharmaceuticals, administration, and insurance than other countries. Its seems like these would be great places to make cuts–however, based on the aforementioned complex I doubt that is going to happen.

DeceasedMD

Mike, you are making me realize that it says a lot for a military general to actually vocalize the problem in those terms “MIC” when most would just play the lucrative game. Is most of the defense work done now in LA or Washington DC? or neither? that must be eye opening to hear first hand from your friends.

Thanks for the OECD link. I think that you bring up another good point and that is that there is some perception that we have all this info at our fingertips with the internet. But there is really no critical thinking involved- a lot of data without a brain essentially. Therefore I especially appreciate the tip on OECD.

Michael

I cannot speak for the bulk of it, but everyone I know in that field is in the VA/DC/MD area.

DeceasedMD

Just curious. Are they mostly engineer types or some admins? In medicine, there were 5 admins to 1 doc I believe in the 90’s. Now it’s a staggering 30 admins to 1 doc. Is there a similar process in the defense world?

Michael

Everyone I know are engineers/programmers, but I do know they they have a huge amount of highly paid admins in both the government and private sectors. For specific ratios I cannot say. I recall being told of one employee (an admin oddly enough) who called them out in a department meeting for having too many GS-15s for the amount of GS-15 level jobs they had. I cannot imagine that was a great career move.

DeceasedMD

yes, perhaps not a good career move:) but it’s pretty bad when they themselves complain about the dysfunction/corruption.

NewMexicoRam

I agree.
This concept that everyone needs to pay for prime rib for those who can’t afford it is relatively new in the timeline of human history. Helping the poor have medical care does not mean we have to fund everything. I’m sorry. That’s just reality. Granted, before socialized medicine, societies may not have gone far enough to ensure that basics are provided, so there is some good from socialized medicine. But that does not mean we have to provide everything (i.e., aggressive, expensive chemotherapy to prolong life by another 3 months in a 70 year old).
We have collective minds. Let’s use them and find an appropriate compromise. Or someday, no one will have anything.

querywoman

Without Medicaid, the hospital has to treat her anyway and eat the bills.

querywoman

I lost my brother a tad too young due to diabetes noncompliance, after approximately a ten year struggle that included three amputations and almost 2 years in a nursing home after passing out due to heart attacks and strokes.
As for the cost of his care, most people would have died sooner than him.
This woman seems to cooperate a little better in the bed. He was polite to his staff, but sometimes he would refuse his meds.
It’s all relative.

lurking for answers

It is not wrong to consider the cost of a thing. If your patient considered the cost that her behavior will have on her life, she may seek to change it for the better. Her behavior will likely cost her life. It is a sad thing to be locked into a way of thinking. She is locked into thinking that she cannot change her circumstances or her behavior. You are locked into thinking that we as a society cannot come to a place of agreement where political party will not trump good ideas. I will have to keep hoping for you both, that someday, you would each broaden your thinking enough to believe that positive change can happen for all of us, in spite of our ideology.

Buddha

We have a patient who lost one leg to amputation before he even saw us. Came to us when we had wound in other leg that was not healing. We worked a liberal schedule for him put him on medications he needed. Fixed a transportation for him so that he can keep different appointments, Spent time working phones to get a wound care consult in local hospital and then got all the wound care supplies and home health care authorized. Patient became fine and then now missing somewhere. He never bothers to follow up on the schedule, pharmacist says never picks up medication; Patient’s brother says patient is now doing hemp and Medicaid did not pay us anything for all the extra things we had to do for this. Ye. Me. I am proud of myself!!!

DeceasedMD

that sucks!

Patient Kit

I wish it was true — that our society takes care of everyone. But we don’t. There are millions of Americans who are uninsured or underinsured who don’t go to the doctor unless it becomes absolutely necessary because they cannot afford medical care. And by then their illness often has progressed to a much more serious and expensive state than it might have been had they gone earlier. Sometimes it is already too late by the time they finally seek medical care. Medical bills are still the number one reason for personal bankruptcy in this country. We do not take care of the working poor and even much of the middle class. We severely undertreat them. We take care of those with money and/or good insurance. In fact, we often overtreat them. We do take care of the poorest via Medicaid. But equal voracity? For more about how many doctors really feel about Medicaid, read the comments on two popular recent blogs here on KMD (one about Medicaid as charity work and the other about angry patients). Many Medicaid patients suffer from the stigma and strereotype of being poor and on Medicaid. We do not take care of everyone, equally or even unequally.

QQQ

“If we had single-payor this would not happen”

We do. Its in the form of Medicare and Medicaid! When you consider we have more than 130 million people currently “covered” by Medicaid and Medicare combined, the United States already is the largest single-payer health provider in the Western world.

querywoman

In the end, they “eat” most of the bills. I’ve been there myself.
My credit has gone down repeatedly and is now gradually improving.
Yet, I usually had money for an apartment and food, except for when I had to live with my mother.
Dentures had to be postponed until I got an insurance check after my mother died.
I’m not scared. I know the laws.
Plus, I have read that hospitals should be advising the uninsured and low income patients of programs to help them with their bills.
That doesn’t mean they will advise them of the programs.
Harassment is very much a part of American business society, and that includes on-the-job harassment as well as collection harassment.

querywoman

Unlike my medically noncompliant brother, this woman appears to be complacent and happy to be getting care.
My brother was terrified and vulnerable during all of his hospitalizations. It showed. The medical staff did what they had to do, knowing he hated getting it, while they dealt with his numb mother and sister who wanted him to have the care.
In the last two years of his life, the nursing home staff knew to ask him about pain because he was infamous for not telling them.
This woman has done nothing to aid her own care. My brother didn’t abuse drugs or alcohol. He was a terrible preventive med person, but a great physical therapy patient.
There are things a person can do. She wouldn’t have to follow a full diabetic diet.
I have a diet soda habit instead of the sugared stuff.
Before I went into full diabetes, I was infamous for getting most of my calories at one meal. I learned from diabetes counseling to eat small meals regularly. I felt better.
I can’t look at people as costing money. I can’t see babies as things that cost money to raise.
There’s not much to say about this, other than that the hospital has no choice but to treat her.
Good luck!